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Friday, January 31, 2014

Are Obama and ObamaCareLosers?

Show me a good loser and I’ll show
you a loser.

Knute Rockne (1888-1931), Notre Dame football
coach

Winning isn’t everything, it’s the
only thing.

Vince Lombardi (1913-1970) Green Bay
Packers football coach

To begin by
comparing football coaches and the game of football to a U.S. President and
his political programmay be a tacky thing to do.But who cares, it's Super Bowl time.

Besides, President ObamaCare is a very competitive
person, the winner of two presidential elections, and I’m sure he will welcome the
comparison because he believes he will win in the end..

At the
moment, Obama and ObamaCare look like potential losers, and Obama isn’t acting like a
good loser, as he vows to lash out against his opponents as obstructions to going foreword by going around them
with unilateral executive actions. The other team is blocking his forward progress.

Characterizing
President Obama as a loser, or as a lame duck, is premature.But it’s hard to argue with polls.They show Obama in the high thirty or low
forty percentages for most approval measures.And there’s no quibbling with the most recent Kaiser Family Foundation
poll. Kaiser, an editorially independent
organization, with no political ax to grind, found the uninsured , who Obama has vowed to help,have an unfavorable view of ObamaCare by a 2:1
margin (47% to 23%).Among all
Americans, the poll finds,the sentiment
is also negative, 50% to 34%.

What’s gone
wrong?No doubt news that 5 to 10
million health plans being cancelled hurts.So do stories of skyrocketing premiums and deductibles. Unquestionably
the botched healthcare.gov rollout plays
a role.So too does ignorance of the law.More than half say they are unaware of the
subsidies.Sixty eight percentof uninsured haven’t even bothered to sign
up. Only 11% of those enrolling were previously uninsured. Forty percent of those who tried to enroll failed.More than half of those polled
have said they have more negative than positive stories about ObamaCare.Bad news sells better than good news, which
may be why ObamaCare is such a hard sell.

None of this
bad news deters the Obama administration which has recruited thousands of
ObamaCare explainors and translators. It has spent $1.4 million in
launching a good news publicity campaign,featuring such celebrities as exercise guru, Richard Simmons, Hollywood celebrities , NFL stars, and other visible
elites to sell the program,all without avail,
at least among the young (18-34) who so far represent only 20% of those signing
up instead of the expected 40% needed to prevent an adverse selection death
spiral.

Among those
fleeing from and distancing themselves from the law are Democrats seeking
reelection in red states,the uninsured,
independents, Republicans,union
leaders,the young,Hispanics, Tea Parties, and growing numbers of women,A motley crew, you say. Perhaps, but
collectively they represent a sizable chunk of voters.

To make matters worst, a December Gallup poll indicates 72% of Americans regard Big Government as the greatest threat to the U.S., and a Fox poll this week found 74% of us think we're still in a recession, five years into the Obama Presidency. Add to these numbers those who see themselves as targets of Obama, the famous 1%, the upper-middle class, Southern states, charter schools, private businesses, politically active conservatives, the Catholic Church, doctors driven out of Obama networks, and the Little Sisters of the Poor, and Obama has a problem on his hands (Daniel Henninger, "Obama's State of Disunion," Wall Street Journal, January 30, 2014).

Of course,
it is not over until the voters vote, Fat Lady sinks,or the Old Gray Lady (The New York Times) and the other media elite run up a
White Flag, which will never be.

It’s a long, long way from February to
November. But as of now, Obama and ObamaCare look like losers, and not good
losers at that as Obama lambasts the
obstructionists and evil-doers among us.

Tweet:As we end January and enter
February ,Obama and ObamaCarelook like potential losers in November.

Thursday, January 30, 2014

Driven from every corner of the
earth, freedom of thought and the right to private judgment in matters of
conscience direct their course to this happy country as their last asylum.

Samuel Adams (1722-1803), Speech,
1776

Is solo private
practice obsolete?

Is it
feasible in this age of nearly universal 3rd party payment, government intrusion, mandatory compliance ,required documentation
of every doctor-patient encounter, and constant calls for coordinated team care ?

These are the
questions I pose in this blog post.

And they are the questions I’ve been asking myself
as I prepare for a talk before the Association of American
Physicians and Surgeons (AAPS).

My answer is: Yes, it is possible to conduct a
solo private in this technological age. Ironically, disruptive computer innovations make it feasible.

APPS defends
private practice. It believes the doctor-patient relationship is a confidential
one-on-one private matter.AAPS maintains the patient should pay the doctor
directly at the point and time of care.The doctor and the patient should agree upon the fee, not the government
or some other 3rd party.And
lastly, when government and other 3rd parties, intervene, the
interventiondestroys the relationship and threatens the
future of private practice.

Is this
belief system realistic?

Not in 3rd party eyes.They
argue for the collective and individual patient good,data is necessary to judge health care “value”-the best outcomes for money
expended.They insist health care has become
so complicated and sophisticated only a team of professionals,using experts’ guidelines based on population
studies, acting in concert, deploying the latest data, can offer optimal
care.

In short, in the words of Edward Deming (1900-1993),
American statistician and quality control guru, “In God we trust, all others
use data.”

This is a persuasive argument,
and I do not disagree with it.But
there are other sides to it -loss of
personal privacy,limitations of
personal choices,restrictions of individual clinical judgment, release of
personal data for all the world to see, desiccated
dehumanization ofthe patient-physician relationship,and physician demoralization.

Physicians often go into medicine
with the belief that their experience and their knowledge of the patient in
face-to-face encounters gives them the right to do what they think is best
for the patient,without having to justify their actions through endless
paperwork, countless phone and online
calls asking permission to order a test or do a procedure, and being
second-guessed at every turn.

This belief system has produced a
movement towards return to individual practices.This return is a reaction against becoming employees of large
organizations,of spending 25% of their
time on paperwork,of being judged and
paid for data on “value” and “performance,” and of sacrificing their
independence for the benefit of organizations, 3rd parties,and the collective good of the “system.”

In a larger sense, what physicians
are doing is decentralizing n in an age ofcentralization and consolidation.

Returning to individual private practices is a difficult thing to do. It requires giving up revenue streams from 3rd parties,losing loyal patients who depend on 3rd
party payment,taking financing risks, entering into a brave
new world of individual care rather than coordinated care, listening to criticsharping and moralizing that it is the wrong thing to do because it creates
a two-tier systembetween those able to
pay and those unable to pay for physician services.

But thousands of physicians are doing it. They are downsizing into solodirect-pay practices.They are doing it with the help of the Internet. They are shedding
the need of large staffs necessary to
deal with the documentation, regulations, restrictions, and hassles that
accompany 3rd party payment.

In the words of Clayton Christensen and his
colleagues at Harvard Business School,

“Nurse practitioners, general practitioners, and
even patients can do things in less-expensive, decentralized settings that
could once be performed only by expensive specialists in centralized,
inconvenient locations. If the natural process of disruption is allowed to
proceed, the result will be higher quality, lower cost, more convenient health
care for everyone.”

Either alone, or with help of s
nurse practitionesr, physician assistants, or other medical assistants,and with routine and imaginative use of the computer, including email communication, physicians are now able to practice in
smaller,more personal,more patient-friendly settings.

Here, in a previous blog post, is how I described the process of disruptive
innovation, decentralization, and individualization works

Gordon
Moore, MD, a family doc, working alone, but on the faculty of the Institute of
Health Improvement, has come up with and implemented,this Wild and Crazy Idea - that One Doc
Working Alone in One Room, with no support staff and nothing but a computer with
Internet access to keep him company, can revolutionize solo practice, by making
it more productive, profitable, and fun.

Sure, I know
it sounds crazy. But he backed and
documentedthe theory and work of his
practice in a medical journal article, “Going Solo: One Doc,One Room, One Year Later.”

In one year,
he did the following:

Maintained
open access scheduling, meaning he saw patients on the day they called; took
his own call, reduced other access barriers, developed deep and personal
relationships with his patients by spending 30 minutes with each one of them; reduced
his patient loadfrom 25 to 30 to 12
patients each day; operated without support staff, in one room of 150 square
feet, averaged $65 per patient visit, and expected to take home $155,000 a
year

Thanks to a
lean IT system and low overhead. He did this with high patient satisfaction
rates,
and a high percent of quality goals met. He built his unorthodox practiceon
these four basic principles:

1) Access. Patients have unlimited
access to the care
and information they need when they need it.

2) Interaction. Interaction between
the patient and care team is deep and personal.

3) Reliability. The system exhibits
high reliability in that it provides all and only the care known to be
effective.

4) Vitality. The practice has
vitality: happy employees, a spirit of innovation, and financial viability.

Along the way as he practiced these principles, he developed and articulated
these philosophical axioms.

“Interaction is not the price we pay to submit a
claim.It is the essence of what we do.”

Tweet:With imaginative computer use,it is possible to run a profitable, productive solo practice satisfying
to practitioner and patient alike.

Yesterday I
interviewed Jane Orient, MD, executive director of the 5000 member Association
of American Physicians and Surgeons (AAPS). She said 3rd parties pay for 85% of care. Yet she advocates that physicians chuck 3rd
parties and rely exclusively on direct pay from patients.

Last night I listened toPresident Obama’s State of the Union address, in which he begged
Americans to sign up for his health law so that every American would have 3rd
party coverage.

These two
events got me to thinking about the raw numbers and why health reform is so
difficult in America without 3rd parties..

Let’s look
at these raw numbers.

There are,
in round numbers.

·315
million Americans

·1
million physicians

·5000
hospitals

·500,000
physicians hospital employees

·50
million Americans in Medicare

·60
million Americans in Medicaid36
million AARP members, a prime source of Medicare supplemental plans

·160
million Americans covered by private plans

·A
health industry spending $2.6 trillion annually

·Total U.S. government spending $3.8 trillion

·An
economy of $16.6 trillion

·A
national debt of $17.3 trillion

·A
health insurance industry with revenue of $663 billion

I If I may paraphrase the late Senator Everett Dirksen of Illinois, "A trillion here, a trillion there, and pretty soon, we're talking about real money."

E Each of
these entities or sectors or phenomena,whatever you wish to call them,has its lobbies, champions, critics, and entrenched interests. Put them in a national mixing container, shake them
up, turn it upside down, and what do you
have- the raw truththat although we have a mixed pluralistic system it is also very ery hard to change, reform, or transform.

I thought of
the raw truth and the raw numbers as I contemplated what I should say in a talk
I’m scheduled to give before the Association of American Physicians and
Surgeons (AAPS)/This is a very
conservative group that considers ObamaCarean obamanation, if you’ll pardon an abominable pun. AAPS
wants a strictly one-on-one relationship between patient and doctor with
patients paying doctors directly.It
calls this direct pay medicine.

Direct pay
doctors are a fringe phenomenon, representing 1 of 2000 doctors,yet they may be emblematic of a larger change
– two tier medicine.In two tier
medicine,the government is one tier. It
provides care for the basic necessities.It is often characterized by less than optimal care with long waiting lines
and restricted or rationed services for those who cannot afford to pay.

The
second tier, provided by the private sector,provides additional care with better care faster access, and more time
with physicians for those able to pay.

John C.
Goodman, a conservative economist who considers himself the father of health
savings accounts, encourages patients to shop for care and to pay for
routine services out of pocket, describes the situations of patients
in these two tiers:

“ In one system, patients will be able to see
doctors promptly. They will talk to physicians by phone and email.
They will have no difficulty scheduling needed surgery. If they have to go into
a hospital, a "hospitalist"
(who reports to them and not to the hospital administration) will be there to
make sure their interests are looked after. They may even have an independent
agency that reviews their medical records, goes with them when they
meet with specialists and gives them advice on every aspect of their care."

"In the other system, waiting times will grow for almost everything- to get appointments with physicians, to get
tests, to obtain elective surgery, etc. Patients may find that they don't have
access to the best doctors or the best hospitals. They may find that the
facility where they are treated does not have the latest technology. In terms
of waiting times and bureaucratic hassles, health care for these patients may
come to resemble the Canadian system. It may become even worse than the
Canadian system."

"The evolution toward a two-tiered system was already under way before Barack
Obama became president. But ironically, the Affordable Care Act (Obamacare) is
accelerating the pace of change. “

The evolution has many facets. Less than 50% of doctors are now accepting
Medicaid patients and in Texas,less
than 60% of patients are seeing Medicare patients. More and more Employers and employees are embracing health
savings accounts,with patients paying
more of the bills, but paying lower premiums and accepting higher deductibles.

And there is a movement towards direct pay
medicine and some of its hybrids – concierge medicine, retainer, medicine, cash
only medicine. Advocates of government deplore this
trend. They say they are immoral, favor the rich, and are non-egalitarian.Yet two tier systems exist at the margins in
all developed countries.

Insurance
companies resist the trends as well, for it dries up a source of new customers
and threatens the very concept of managed care,that its experts know best what it good for its customers and protects
them against excessive care.

And government? Well, progressive government's very reason for being is providing entitlement programs to retain political power.

Will the second tier grow?Will more
physicians choose to enter direct pay practices?Will more choose not to accept Medicaid and
Medicaid patients?Yes, but there will
be sharp limits.

Just look at the raw
numbers. Ninety percent of physicians depend of 3rd parties for their cicnoems. The number of Americans who depend on Medicaid and Medicare will grow from
110 million to 150 million by 2020.Employers
will continue to cover 160 million Americans, although the numbers may diminish
slightly. The number of physicians employed by hospitals will grow.Hospitals will depend on Medicare and
Medicaid for more than 50% of their revenues.

Self-interests, perhaps I should say,
entrenched interests, will protect their turf.In Minnesota, where I am speaking before AAPS, UnitedHealthGroup is the
state’s largest employer.System
wide,it has over 100,000 employees,
covers 70 million people, and has over $7 billion in revenues.United and other health insurers are not going to go gently into that good
night of independent practices stripped of 3rd pqartie,s , now will the federal government.

Tweet:Raw
numbers indicating the size, scope, and revenues of major health are players
preclude any major return to independent medical practices.

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.